1750443073 NPI number — DR. KRISTI LYN KOZLOV LLC

Table of content: DR. KRISTI LYN KOZLOV LLC (NPI 1750443073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750443073 NPI number — DR. KRISTI LYN KOZLOV LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOZLOV
Provider First Name:
KRISTI
Provider Middle Name:
LYN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750443073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 SPRING HILL RING RD
Provider Second Line Business Mailing Address:
STE 2020
Provider Business Mailing Address City Name:
WEST DUNDEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60118-1297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-771-2007
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 OGDEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LISLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60532-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-527-1920
Provider Business Practice Location Address Fax Number:
630-527-0125
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  036103302 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02233058 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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